: The rates of maternal and neonatal mortality remain significantly above the objectives for the new millennium. The proposed research will examine whether a woman's pre-pregnancy health status explains, in part, the persistent racial disparities in adverse perinatal outcomes in the United States. A multi-ethnic cohort of 2,400 women in the San Francisco Bay Area will be followed throughout pregnancy until they are three months post-partum. We will recruit women who will deliver at one of three sites: an academic health center, a public hospital, and a large group model HMO. We will collect standardized, self-reported information on pre-pregnancy health status and objective clinical data from medical records to examine whether a legacy of chronic health problems and poor health status are related to an increased risk of adverse perinatal outcomes. Our research is based on the hypothesis that the prenatal period is too late to address the legacy of chronic health problems and poor health status of African-American and disadvantaged women. Cohort characteristics will be grouped into three broad categories: (1) race and other sociodemographic characteristics, (2) pre-pregnancy factors, and (3) current pregnancy factors. Data will be analyzed to examine whether disparities in adverse outcome are explained by pre-pregnancy maternal health status. We will examine two primary outcomes variables: (1) an aggregate indicator of adverse neonatal outcome, and (2) an aggregate indicator of adverse maternal outcome. These data could have significant health policy impact. While all states provide insurance coverage for prenatal care for poor pregnant women through Medicaid, only Hawaii extends coverage to eligible women regardless of pregnancy. These data may address whether more continuous coverage for reproductive age women is appropriate. The long-term goal of this investigation is to inform public policy so that discrete interventions can be designed and implemented to reduce the health risks of women prior to pregnancy. Such interventions should begin from the premise that improved maternal and infant outcomes can only come from improved maternal health.